Abstract
Cancer, like other chronic illnesses, changes the patients’ way of living significantly. Although some may think, for instance, that religiousness would increase with the diagnosis of cancer, no previous studies have been performed in the Turkish society to confirm this. We, as the Turkish Oncology Group, conducted a survey in seven different oncology centres, representing a large majority of Turkey, to investigate how patients’ lifestyles changed following a cancer diagnosis; we used dialysis patients as a chronic illness control group. The study findings showed how changes in spiritual practices are completely in line with what is observed in other chronic illnesses. These findings may help to address cancer patients’ needs and facilitate resource allocation accordingly.
Introduction
Spirituality is one of the most important issues for end-stage cancer patients (Balboni et al., 2007; Camargos et al., 2015). Oncological diseases are similar to chronic yet treatable diseases like diabetes or renal failure, which require dialysis, in that they may cause some changes in a patient’s perception of life. The role of religiousness on the course of different diseases was previously evaluated by a number of studies, and the common finding in these studies was that spirituality was an important factor for coping with physical disease (Feher and Maly, 1999; Janiszewska, 2001; Koenig et al., 2004). This finding was also reported in another study, which found that coping with disease with the help of religious sources was most likely to occur in cancer patients (Sherman and Simonton, 2001). They showed that illness-related religious coping was more strongly tied to the outcomes their assessed than was general religiousness. However, patients’ typical involvement in religion was not related to psychosocial or physical functioning. Of patients with cancer, their religion had greater difficulties with general distress and depression, and to a lesser extent, with pain, fatigue and daily physical functioning.
Similar results have been reported in the literature on this topic, which note that spirituality and the course of a disease affect each other (Balboni et al., 2015; Delgado-Guay, 2014; Gall, 2004; Jim et al., 2015; Lai et al., 2016). According to the results of some studies, receiving a diagnosis for a life-threatening disease is the first traumatic change in one’s life that precedes the re-evaluation of his or her spiritual beliefs (Feher and Maly, 1999; Moschella et al., 1997).
Spirituality may be particularly important for individuals facing terminal illnesses because of the many physical, psychological, and social stressors that often accompany life-threatening diseases. Spirituality is strongly and negatively associated with depression in individuals coping with a terminal illness. Nelson et al. (2002) showed that there were interrelationships among depression, spirituality and religion in terminally ill populations.
The spiritual attitudes of cancer patients are especially important, and this topic is generally under-addressed by health care providers (Kristeller et al., 1999). In this study, we assessed patients’ religious changes and determined the extent to which these changes occurred upon receiving a specific diagnosis, so as to draw attention to this critical issue.
Materials and methods
We approached patients who were in the waiting rooms of chemotherapy units, dialysis units or outpatient clinics and asked them to fill out a two-page questionnaire consisting of 22 questions. As control group, patients in dialysis units were selected because chronic renal failure is a progressive and irreversible disease. In addition, we asked them to describe their thoughts regarding these various variables. Patients filled out the questionnaires themselves, but nurses were available to answer any questions. Both male and female patients were included in the study. The exclusion criteria included (a) patients who refused to fill out the form, (b) patients who were expected to receive active dialysis treatment and had a diagnosis of oncological disease for more than 4 weeks and (c) patients who were younger than 18 years. Obtained data were analysed with SPSS software (version 15.0). Paired Student’s t-test was used to analyse quantitative data and McNemar’s test to analyse qualitative data.
Results
A total of 235 patients were included in this study. The patients’ baseline characteristics are illustrated in Table 1. Males and females were equally distributed. The mean age of the patients was 50 ± 13 years. Male patients were slightly older than females (mean age of 51 vs 49 years, respectively), but the difference was not statistically significant. Approximately 55 per cent of the patients were diagnosed with their illnesses during the last 12 months, and 72 per cent of them had been given a diagnosis of cancer. Of all the patients, in this study, 54 per cent were elementary school graduates. The percentage of patients with college degrees (or higher) was 19.
Baseline characteristics of the study patients.
SD: standard deviation.
p value between patients with and without cancer.
When we looked at some of the changes that occurred in the patients’ lifestyle upon being diagnosed with a chronic illness, we observed that the use of alcohol and tobacco showed a statistically significant decrease (17% vs 5% for alcohol, p < 0.001; 44% vs 11% for smoking, p < 0.001). When we looked at patients with cancer versus other diseases, the use of tobacco and alcohol decreased significantly in cancer patients. Smoking decreased in patients with other chronic illnesses, although the reduction was smaller than the reduction observed among cancer patients. We found no evidence that the use of alcohol changed following the diagnosis of these chronic illnesses. There was also a similar difference observed in the patients who were diagnosed within the last year and those that were diagnosed within the last few years. Both groups showed a statistically significant decrease in smoking (p < 0.001). However, in patients who were diagnosed with cancer for longer than 1 year, the decreasing ratio of their alcohol use was similar to these who were new diagnosed with cancer.
Religious practices in the survey sample were assessed. Following diagnosis, patients’ fasting practices decreased by 45 per cent, and a patient’s intention to go on a pilgrimage decreased by 25 per cent (Table 2). In both cases, the reductions were statistically significant (p < 0.001). Worshipping, giving money to the needy and praying decreased by 9, 6 and 6 per cent, respectively, but the differences were not statistically significant (p = 0.248, p = 0.267 and p = 0.180, respectively). If the patients had a tendency to pray regularly before receiving their diagnosis, there was a 6 per cent decrease in this tendency upon being diagnosed. However, in people who did not pray regularly before the diagnosis, 17 per cent of them started to pray after the diagnosis. When we did a sub-group analysis, we observed that cancer patients had changes in fasting practices and their intention to go to pilgrimage, but there were no changes in terms of worshipping, giving money to the needy and praying (p = 0.178, p = 0.166 and p = 0.1, respectively). When we looked at patients with chronic illnesses other than cancer, we observed that none of these factors changed after the diagnosis. We asked the patients whether they needed any spiritual help, and the patients reported that they needed such help 46 per cent of the time prior to diagnosis and 45 per cent of the time after the diagnosis. Thus, there was no change. More than 13 per cent of the patients’ thoughts on these practices changed, but there was no significant difference noted between the patients with cancer and patients with other chronic illnesses (p = 0.057 and p = 0.999, respectively). The patients stated that they would like to get spiritual help from religious personnel 35 per cent of the time, from family 90 per cent of the time and from health care workers 14 per cent of the time. A total of 64 per cent of patients stated that it would be helpful to have a religious person at the health care facility in case they needed help. No difference was found on this parameter between the patients with a cancer diagnosis and those with another illness. The percentage of patients who reported that their religious beliefs increased after the diagnosis was 27; 9 per cent stated that it decreased after the diagnosis. The increase was 23 per cent in patients with cancer and 49 per cent in patients with other chronic illnesses (p = 0.003). We found no evidence (p = 0.875) of an effect of the date of diagnosis (i.e. longer or shorter than 1 year).
Differences in the behaviours and lifestyles of the patients before and after the diagnosis according to type of disease.
Into the groups; **between the groups.
Discussion
When people face chronic illnesses or illnesses that are perceived to be fatal (such as cancer), their attitudes towards life and spiritual issues may change. Changes in a patient’s general attitudes in his or her daily lifestyle can be generalized under the topic of post-traumatic growth, and beneficial spiritual growth can be considered a component of this process (Sears et al., 2003). The changes in one’s religious habits and practices are frequently a part of coping with anxiety after being diagnosed with a serious medical condition such as cancer. Tix and Fraser (1998) described religious coping as ‘the use of cognitive and behavioural techniques, in the face of stressful life events, that arise out of one’s religion or spirituality’. The cognitive changes following a diagnosis may present as an increasing belief in the presence of God or spiritual powers, and behavioural changes may take the form of engaging in religious activities. These changes in patients’ religious habits were also observed in our study group. Major changes were observed in terms of fasting and pilgrimage activities, which had decreased significantly.
However, a more striking finding in our study was that the patients’ praying habits changed. The frequency of regular prayers before the patients’ diagnosis had slightly decreased after being diagnosed with a serious illness, and controversially, approximately one-fifth of non-prayers began to pray after they found out about the change in their medical condition. According to data from the current literature, these changes generally depend upon the main factor that causes the psychological stress experienced, the patient’s characteristics and any situational factors, such as the current state of the disease (Spilka et al., 1985). These data were also confirmed by our results, as we found that these changes were more prevalent in patients with cancer, but not in patients with other chronic medical conditions. It was previously reported that a cancer diagnosis may be an important factor for one’s engagement in spiritual activities (Sherman and Simonton, 2001). Also, these activities are related to the degree of personal threat that one might perceive, and since cancer is generally a major life-threatening medical condition, it has a substantial effect on one’s spiritual behaviours (McCrae, 1984).
There are some limitations in our study. First, it was a questionnaire study. Thus, the results were based on statements of patients. Second, our study was a non-randomized study and the study population consisted of heterogeneous groups. Third, the number of patients without cancer was lower than those with cancer. This heterogeneity may affect the results of the study.
It should be noted that the changes in spiritual behaviours and activities were not as great as we had anticipated before we conducted the study. These findings should be confirmed with larger case-controlled studies. Cancer patients’ spiritual needs do not change dramatically after the diagnosis of cancer, but still some steps needs to be taken to fulfil this need.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.